Disaster Preparedness for Nurses Janie Rigsby Mt. San Jacinto College Advanced Medical Surgical Nursing Nursing 244 Cheri Levy, RN, BSN September 07, 2010
Disaster Preparedness for Nurses Healthcare regulating agencies have recently enacted many changes regarding disaster preparedness and emergency management standards. This paper will discuss what constitutes a disaster, the components of disaster preparedness, and hospital regulations that pertain to emergency management. Bioterrorism and disaster will be compared and contrasted in an effort to clarify their impact on the healthcare community. Disaster Preparedness A disaster is an event wherein forces overwhelm a community in such a way that services are compromised (Veenema, 2006). Disaster situations usually require outside assistance due to the fact that resources close to the event are negatively impacted. Disasters can be natural such as an earthquake or man-made which would include transportation accidents, nuclear events or bioterrorism (Veenema, 2006). Prior to a disaster occurring, efforts to anticipate problems can proactively put policies in place to manage emergencies. Some disasters trigger warning signals wherein the public may be made aware of the ensuing event. After the emergency occurs, the affected area must be isolated and a remedy should be enacted. Beyond that, recovery may take years and at times, full recovery may not be possible. The components of emergency management are preparedness, mitigation, response, and recovery (Koenig, 2007). Preparedness is the key component for disaster management. Hospitals must be in compliance with many regulating agencies such as the Joint Commission and Center for Medicare and Medicaid Services (Koenig, 2007). The hospital must perform a hazard vulnerability analysis to determine whether the hospital is located near a nuclear power plant or if there is a hurricane risk (Koenig, 2007). Comprehensive Emergency Programs (CEM) have been adopted in an effort to standardize the nomenclature for Joint Commission on Accreditation
of Healthcare Organizations (JCAHO) standards (Koenig, 2007). Preparedness also entails staff orientation, rehearsal and training regarding each member’s role in the emergency. A call-in line or website should be set-up to communicate with staff. Resources must be contracted prior to the event and agreements made ahead of time. The importance of managing resources was experienced during Hurricane Katrina where a sole busing company was contracted to evacuate nursing homes. That company was unable to provide this service so several companies are now in charge of that task (Veenema, 2006). Emergency operation plans allow hospitals to identify their ability to provide services for 96 hours should that hospital fail to be supported by the community (Veenema, 2006). Alternate sites for care should be pre-arranged. Mitigation is the second component of disaster preparedness. Hazards must be evaluated as well as vulnerability. Events that threaten the hospital environment must be mitigated (Veenema, 2006). Actions must be taken to ensure that systems will be functional should an event occur. Logistics must be managed such as how to replenish medications and supplies as well as how to maintain utilities. Security must manage access to the hospital and coordinate traffic control measures (Veenema, 2006). Hospitals must coordinate disaster drills in response to an actual emergency or to a simulated drill. These exercises allow organizations to test their procedures and discover and deficiencies (Ignatavicius & Workman, 2010) Response is the third component of disaster preparedness. Staff must be prepared to be activated in the event of an emergency. The staff must also prepare their families in the event that the emergency requires the staff members’ presence for an extended period of time (Ignatavicius & Workman, 2010). On-call lists should be maintained and be current, command structures and personnel assignments should be in the form of a facility organizational chart (Berman, Erb, Kosier, & Snyder, 2008). Critical staff should be trained in organization and
operation of triage situations. Nurses must be adept with situation assessment, management of care, infection control and safety. Sanitation, nutritional, and mental health needs must be coordinated in conjunction with social services (Koenig, 2007). Use of personal protective equipment should be mandatory. Response is necessary for the hospital as a facility as well. Warnings and notifications require communication with the news media. The emergency preparedness plan will be activated which may send a cascade of events into play. Waiver authority can be utilized to modify Medicare and Medicaid requirements (“Authority to waive requirements during national emergencies“, 2005). JCAHO has also approved Disaster Privileging requirements so that in the event of a disaster, hospitals may grant disaster privileges to volunteer practitioners (“Disaster Privileging Requirements“, 2006). In Nevada, Universal Badging Systems (UBS) was created to provide a means of reliable and secure form of identification (Universal Badging Systems, n.d.). Recovery includes all programs and actions that attempt to return the environment to predisaster status. Nurses should adjust patient care and set priorities and objectives according to the present level of care. The hospital should offer stress relief for clients and staff (Berman et al., 2008). A committee should be implemented to critique the response and make recommendations to the emergency plan (Ignatavicius & Workman, 2010). Bioterrorism and Disaster Ignativicius (2010), states that bioterrorism is the use of biologic agents to terrorize. Veeneme (2006) defines bioterrorism as “the intentional release, or threatened release, of disease-producing living organisms or biologically active substances derived from organisms for the purpose of causing death, illness, incapacity, economic damage, or fear”. Nurses are very much in the center of disaster situations and bioterrorism could be the reason for the disaster.
Biological agents can be used for biological warfare but infectious diseases that are found in nature also present challenges to nurses. The incidence of several infectious diseases, such as “severe acute respiratory syndrome (SARS), bovine spongiform encephalopathy (BSE), avian influenza, and monkeypox, and the re-emergence of mutated diseases, such as tuberculosis, have increased” (Veeneme, 2006, para. 4). Rebmann (2005), states that nurses must have adequate education and training in order to deal with a stressful situation such as a bioterrorism attack. Nursing curriculum has recently embraced disaster and emergency preparedness (Rebmann, 2005). Disaster can be defined as a calamitous event, especially one occurring suddenly and causing great loss (Berman et al., 2008). Bioterrorism and disaster are very much alike in that any terrorist attack has the potential to be a disaster. Early recognition and detection are essential to isolating the offending organism as well as affording enough time to seek medical treatment (Veeneme, 2006). One example of a bioterrorist act occurred during the aftermath of the tragedy on September 11, 2001. Anthrax was used as a vehicle to kill five people and infect 17 others (Greenemeier, 2008). This was an unprecedented national disaster. Bioterrorism and disaster are somewhat different as well. Disaster defined could include bioterrorism but is not mutually exclusive. One can have a disaster without terrorism being the cause. Many disasters are natural disasters such as Hurricane Katrina or the tsunami that flooded Haiti. Recent man-made disasters include the oil spill off the coast of Louisana, and the nuclear accidents at the Marshall Islands, Three Mile Island and Chernobyl (“Man-made Disasters“, 2008). Bioterrorism and disaster differ in that bioterrorism is an intentional act and a disaster may not be intentional.
Southwest Health System Policy and Procedures Southwest Healthcare System (SWHS), in coordination with the Joint Commission, has developed an Emergency Preparedness Management Plan. The compilation can be found on the Intranet within the Southwest computer system. The actual manual is within the SWHS Policy and Procedure Manual under Environment of Care (EOC) (Southwest Healthcare System Policy and Procedure website, 2002). The goal of this plan is to identify team roles in the event of an emergency and moreover, the responsibility of the hospital to the public. Administration is the nucleus for the administration of this plan. According to Daub (2002) the most obvious goal is to meet low-probability, high consequence events such as bioterrorism can also elevate day-to-day healthcare operations and services. Understanding how to accomplish this, as well as identifying what capacities are needed for development or enhancement, depends on a structured approach to needs assessment. Integrating and automating hospital and other response agency preparedness assessment activities assures that necessary capacities are identified and that coordinated response systems are developed (p. 7). Preparedness in Common with Local Agencies Administration is responsible for coordinating local agencies in the implementation of the disaster plan. Disaster drills must be completed in-house as well as within the community. The following are just a few examples from Daub (2002, p.3) of the many considerations administration may have:
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Recognition of a bioterrorist-related condition Potential epidemic involving at least 500 patients Critical partner relationships
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Personnel and care provider notification Increase bed capacity to accommodate at least 500 patients Isolation and quarantine for casualties Hospital diversion and rapid communication with Emergency Medical Services Special need so children, pregnant women, the elderly and those with disabilities Provision for increases in staffing Facility evacuation and patient transfer Alternate site designation Communication (internal/external) Back up utilities Receipt of the National Pharmaceutical Stockpile Media response Triage of the ill and worried well Laboratory capacity and referral Hospital security Protection of staff and their families Disaster Command Center
The Command Center may include the Administrator that is on-call, Medical Chief of Staff, Runners, Walkie-Talkie Operator, Documentation Recorder and House Supervisor. These people will “Maintain an overview of emergency needs and hospital resources (Southwest Healthcare System Policy and Procedure website, 2002, para. 2). The Command Center will also keep records, serve as a communication center, assess for supplies, equipment and staffing during the disaster and coordinates bed availability with other facilities (Southwest Healthcare
System Policy and Procedure website, 2002). Walkie-Talkie operators will be assigned to Triage and the Emergency Department; Medical and non-medical labor pools will send a representative to the Command Center for instructions and updates (Southwest Healthcare System Policy and Procedure website, 2002). Each department will keep a list of on-duty and off-duty staff available for assignment, maintain records of assignments and makes calls as required to obtain necessary staff (Southwest Healthcare System Policy and Procedure website, 2002). The triage area is established by the Emergency Department nurse and physician on duty. Staffing should include a physician, nurse, admitting clerk, medical records clerk, Walkie-Talkie operator and a runner. Triage victims are based on acuity such as emergent (care within one hour), urgent (care within 4 hours), and the walking wounded (care within 8 hours), and minor care (Southwest Healthcare System Policy and Procedure website, 2002). Victims will be identified by a disaster tag number, names placed on a Casualty Flow list which will be tracked as the disaster progresses (Southwest Healthcare System Policy and Procedure website, 2002). There will be a family waiting/discharge area staffed by a Risk Manager, Chaplain, runner, Social Worker and volunteers. This area will provide food to families and serve as a type of command center for information about treatment and care (Southwest Healthcare System Policy and Procedure website, 2002). Staff Responsibilities in the Disaster Plan Staff has responsibilities to the community, hospital, and clients. The Joint Commission on Accreditation of Healthcare Organizations (2003) acknowledges the risks that healthcare workers face when they respond to a crisis. “Staff members need to be trained and be provided proper equipment to reduce the risk of an unsafe response… staff must also have the highest priority for prophylactic antibiotics, chemical antidotes, and other practical therapeutic measures
(The Joint Commission on Accreditation of Healthcare Organizations [JCAHO], 2003, p. 24). The hospital should provide decontamination areas for employees. Vaccinations, mental health, communications support, provision of transportation, and attention to child-care needs are necessary to facilitate meeting the needs of staff members (JCAHO, 2003). Specific responsibilities of the staff are included in the SWHS Policy and Procedure website (Southwest Healthcare System Policy and Procedure website, 2002). Staff must accept training in the safety features of the work environment, know evacuation routes, and be willing to implement their assigned duty in the event of a disaster or bioterrorism attack (Southwest Healthcare System Policy and Procedure website, 2002). Staff should provide treatment areas and site management in the event of a mass casualty situation. Coordination of care and plans to recruit other medical professionals should also be initiated (Southwest Healthcare System Policy and Procedure website, 2002). Individual clinical staff responsibilities can be department specific as well as part of a general “pool” of healthcare providers. An example of department specific would be phlebotomists that stay with immediate blood draws while other phlebotomists may report to the Emergency Department (Southwest Healthcare System Policy and Procedure website, 2002). Non-medical staff has alternate responsibilities in the event of a disaster or bioterrorism attack. Electrical, heating, ventilation, plumbing, gas, vacuum, and data exchange report to the Labor Pool in anticipation to perform the stated duties within the SWHS Policy and Procedure Manual (Southwest Healthcare System Policy and Procedure website, 2002). The SWHS (2002) website states that in the event of a bioterrorist event, the emergency response system is activated and notification should include:
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Safety Officer Infection Control personnel Local emergency medical systems Police and Fire Departments Local and state health departments Federal Bureau of Investigation field office Center for Disease Control
The Infection Control team would be asked to designate an area for the media, for decontamination and for labor assignments. Specimen packaging, handling and documentation must be done with the chain of command in place (Southwest Healthcare System Policy and Procedure website, 2002). Security personnel will lock all exits except for the ambulance entrance (Southwest Healthcare System Policy and Procedure website, 2002). Medical staff and employees will have to carry an identification badge in order to gain access to the hospital (Southwest Healthcare System Policy and Procedure website, 2002). Cohorting of patients with the same symptoms may be necessary. Environmental cleaning will be performed according to Standard Precautions (Southwest Healthcare System Policy and Procedure website, 2002). As of the writing of this paper, materials were not available to document on the specifics of all staff responsibilities.
References Authority to waive requirements during national emergencies. (2005). Retrieved from http://www.ssa.gov/OP_Home/ssact/title11/1135.htm Berman, A., Erb, G., Kosier, B., & Snyder, S. (2008). Fundamentals of nursing; Concepts, process, and practice (8th ed.). Upper Saddle River, NJ: Pearson. Disaster Privileging Requirements. (2006). Retrieved from http://www.jcrinc.com/CPMS10/Extras/ Greenemeier, L. (2008). Seven years later: Electrons unlocked post-9/11 Anthrax Mail Mystery. Retrieved from http://www.scientificamerican.com/article.cfm?id=sandia-anthraxmailing-investigation Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed.). St. Louis: Saunders Elsevier. Koenig, K. (2007). New standards in emergency management: Major change in JCAHO requirements for disasters. Retrieved from http://www.acep.org/Acepmembership.aspx? id=38298 Rebmann, T. (2005). Defining bioterrorism preparedness for nurses: Concept analysis. Retrieved from http://web.ebscohost.com.proxylib.msjc.edu/ehost/pdfviewer/pdfviewer? vid=22&hid=105&sid=ea40f595-a01f-45ac-8888-e4c9d45e8e29%40sessionmgr113 Southwest Healthcare System Policy and Procedure website. (2002). http://swhsms45/sites/swhcs/policies/SWHCS Policies and Manuals/7-0103 Emergency Preparedness Management Plan 2-02.doc The Joint Commission on Accreditation of Healthcare Organizations. (2003). Health care at the crossroads: Strategies for creating and sustaining community-wide emergency
preparedness systems. Retrieved from The Joint Commission website: http://www.jointcommission.org/NR/rdonlyres/9C8DE572-5D7A-4F28-AB843741EC82AF98/0/emergency_preparedness.pdf The world’s more bizarre man-made natural disasters. (2008). Retrieved from http://www.huffingtonpost.com/2010/05/11/the-worlds-most-bizarrem_n_571043.html#s89554 Universal Badging Systems. (n.d.). http://www.nvha.net/bio/ubs.htm Veeneme, T. (2006). Early detection and surveillance for biopreparedness and emerging infectious diseases. Retrieved from http://web.ebscohost.com.proxylib.msjc.edu/ehost/detail? vid=25&hid=105&sid=ea40f595-a01f-45ac-8888e4c9d45e8e29%40sessionmgr113&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d %3d#db=jlh&AN=2009196786 Veeneme, T. (2006). Expanding educational opportunities in disaster response and emergency preparedness for nurses. Nursing Education Perspectives, 27, 93-99. Retrieved from http://healthsourcenursing/academicedition